So I’m delighted to see milestone, of a sort, achieved… a major health IT consortia is tackling in interoperability, and leveraging workflow technology, AKA Business Process Management (BPM) at the core of its “marketecture”.

“Healthcare Services Platform Consortium, a group of providers, IT vendors, system integrators and venture-led firms dedicated to solving the industry-wide interoperability problem.”

Read HSPC Incorporates, Gears Up to Tackle Interoperability Problem and then take a tour of slides from their slide deck. Take a look at the marketecture layers in the above slide: workflow, process, business model…. Then, there’s the title: Seamless Service Orientation with BPM and SOA. SOA stands for Service-Oriented Architecture. Those are the building blocks. But what puts the building blocks together? What is the usability cement combining the bricks into seamless whole? Business Process Management!

Now closely examine the next slide. “Workflow SDK… Intercepts actions and events on the OS level… Monitors state of every application… Delivers a seamless in the workflow integration.” What we’re essentially talking about here, is, a retrofitting of workflow-oblivious health IT legacy applications with the more modern process-aware BPM technology. The reason actions and events are intercepted at the operation system level, is there’s a natural decomposition of here, between app and OS. The apps may be monolithic. The OS may be monolithic. But there’s a place, between app and OS, where communications between apps and OS can be captured. Language translation systems often use this same technique. An app sends “Hello” to an OS managed dialogue box. The “hello” is trapped between app and OS (which manages dialogue boxes) and substitutes “Hola”. It will be very interesting to see is this approach will work.

Now the following slide is the key, the key to combining two healthcare subdomains crying out to be reunited. On one hand we have the process improvement folks (quality improvement, Lean, 6 Sigma, etc.). On the other hand, processes are so mediated by software that they are essentially DICTATED by software. This is why doctors hate EHRs! The doctor’s workflow is different from the EHR’s workflow. But, unfortunately for the doc, it’s actually painfully EASIER to change the doctor’s workflow to fit frozen health IT workflow, than to change health IT workflow to fit the poor doc’s workflow. So many of our problems today, in the health IT industry, boil down to this unfortunate fact.

What is to be done? CHANGE THE FACTS. That is, change what economists call the Production Function, and the rest of us engineers, scientists, analysts, and programmers call “technology.” And, if we change workflow-oblivous health IT technology into process-aware health IT technology, we can achieve a virtuous cycle. The processes that process improvement folks are trying to improve are locked up in software. But that software is directed by representations of workflow that can be improved by users editing process definitions and, increasingly, automatically through machine learning (Think Google Now for Health IT).

Compare the previous slide, from the HSPC slide deck, with the virtuous cycle rounding from workflow and process design, though execution and monitoring, then through simulation and optimization, and finally back through design and implementation of improved workflows and processes, with the following slide from one of my webinars several years ago. In this webinar the topic was the advantage of adding BPM technology to an ECM (Enterprise Content Management) system: Enterprise Content Management & Business Process Management: A Healthcare Game Changer.

THEN compare both slides to this classic depiction of the BPM life cycle from its Wikipedia entry.

All three of the previous diagrams, from the HSPC slide deck, my own slide about BPM and ECM, and the BPM Wikipedia entry, emphasize the virtuous cycle of process improvement that current workflow-oblivious health IT makes very difficult. In fact, one definition of BPM is, the “process improvement process” (done on steroids, with the right software.

By the way, one of these days I’ll put the aforementioned webinar online, including recorded narration, on YouTube. In the mean time, check out my BPM & Case Management: Healthcare Needs You! YouTube video.

Glad to see BPM pressed into use to tackle healthcare workflow interoperability!

P.S. I’m very interested in which BPM platform they will go with…. I suspect it will be one which one of the consortium partners already uses…. which means it might be… or … 🙂 …. Whoever’s BPM stack is adopted, that is an enormously strategically powerful position in which to arrive!

You wouldn’t confuse your baseball card collection with the Microsoft Access database management system you use to manage it. Or confuse your patients with your EHR. But people, especially in healthcare, confuse workflows with workflow management systems all the time. I’ve discussed this important distinction before (EMR Workflow Systems vs. EHR Workflow Management Systems). But I think it is worth revisiting. Confusing workflow with workflow technology is what gives rise to the notion that introducing process-aware information systems into healthcare and health IT is mere “tweaking” of workflow.

Workflow is what actually happens when work is done. It is a series of steps, or tasks, that consume resources (money, time, effort, attention), and achieve one or more goals. Virtually all purposeful activity involves workflow.

Workflow technology, on the other hand, has some sort of model of workflow. This is model is executed or consulted, in conjunction with human users, when they do their jobs. These executable process models are at the heart of what distinguishes healthcare workflow technology from generic healthcare information technology. All information systems “affect” workflow (that is, influences workflow, for good or ill). But healthcare workflow technology “effects” workflows (that is, drives, makes it so, in the Captain Picard, Star Trek sense).

Why do I harp upon workflow technology all the time? Because it is the next generation of application architecture heading down the pike toward health IT, which is about a half a generation or more behind other industries. Sometimes folks say, “So what! Fix the incentives and the tech will fix itself.” I agree we need to fix healthcare incentives (whatever that means, I hear lots of strenuous debate about that particular topic). But even if we fix the incentives, billions of dollars have cemented frozen healthcare workflows into place. Similar to, by analogy, early human proclivities (such as eating until overfull in the presence of food) plaguing us this modern day, a decade of frozen health IT workflow will resist pressures to change for the better, if the better even presents itself.

Furthermore, regardless of which incentive regime we finally impose, it won’t work unless we have true workflow technology to make it work. It doesn’t matter, free market vs. socialized medicine, Meaningful Use-driven software development vs. Meaningful Use-Be-Gone-driven software development. We will have invested so much in workflow-oblivious, workflow-frozen healthcare information systems, that (A) they’ll be too expensive to change, and (B) we won’t have enough will or resources left to change them. We need to begin making our health IT systems more process-aware, now.

Moving to executable models of work is not merely tweaking workflows. It is moving to a more flexible, effective, efficient, transparent and systematically improvable substrate in which to realize whatever systems of healthcare incentives we ultimately move to. And I can guarantee you one thing. We won’t get them right the first, second, or even third time. That’s why we need to create systems of health information management in which workflows can be more easily “tweaked.”

Last Friday, for my first time, I moderated one of the weekly 12-1 EST #HITsm tweetchats. Of course the topic was healthcare workflow. You can see my questions below, plus some of the most interesting tweets from participants. Healthcare workflow did well as a topic! Compared to the three previous August #HITsm sessions for 2014 and 2013 (to adjust for seasonal fluctuation) we generated about 40 percent more tweets than average.

Many thanks to the #HITsm regulars, for their warm welcome to the workflow-oriented Twitter accounts I invited. And even more many many thanks to the #HITsm “irregulars” for accepting my invite and participating so enthusiastically! #HITsm regulars are really smart, but, ultimately, if workflow flexibility, transparency, effectiveness, efficiency, quality, consistency, throughput, and user and patient satisfaction are to be substantially improved, it is going to take more than opinions. It’s going to take actual products and services and consultants to help EHR and Health IT users to take back their workflows. (Hmm, Occupy Workflow?).

In no particular order, folks I (think (memory’s a bit hazy) I) invited and showed up! Thank you to you all, but especially the following folks!

It was super exciting to see so many new faces! I spoke to several participants afterwords. Both said they’d picked up some new followers. It is my fervent hope to see more health IT folks following workflow tech folks and workflow tech folks following health IT folks. The hybrid vigor of this intellectually exchange cannot lead anywhere except good places.

@Colin_Hung won the workflow book give away by tweeting the most on the #HITsm hashtag between 12 Noon and 1 PM EST. (Colin, please contact me!)

I kicked off this #HITsm tweetchat with an open-ended question about flowcharting experiences, good and bad, because almost everyone (well, that I know) has drawn a flowchart of some workflow or other. It might be to just introduce do a new team member to “the way things are done around here” or it might be part of a quality initiative or it might even be part of gathering user requirements for a new information system. (And, I should mention, it might even be drawn using a graphical workflow editor and then executed by a workflow engine!)

This next question, about “Lifehacking” is just something fun, though it does have a point. It’s the multitude of little things we do to improve our personal and professional workflows that add up to great workflow. I strongly suspect that folks who are great of managing their personal workflows are great at managing their professional and workplace workflows. Conversely, I’ll bet these folks can be the most frustrated when it comes to “workflow-obvious” difficult-to-customize EHR and health IT systems!

I’ve become very interested in what I call “wearable workflow”. If you think of workflow as a series of tasks, consuming resources (especially attention), to achieve goals, then wearable tech certainly affects our workflows, in the lifehack sense. Yes, there’s all that data sent heaven-knows-where by our FitBits and such, but it’s notifications that I’m focusing on here. Email, SMS, tweet, upload succeeded, upload failed, how to I move my focus of attention from Google Glass to my smartphone? How do I filter notifications so my smartphone only goes off for the most important one? That’s the kind of wearable workflow I’m taking about. For example, Google Glass startups are getting millions of dollars of investment just to reduce reliance of providers on EHR “clunky” workflow. The permutations are endless! Smartglasses, smartwatches, smartphones, smartrings, smartshoes…. what if they all “go off” at the same time?! We, especially in healthcare, where workflow workflow can do so much good, are also especially bombarded with alerts and reminders. We need some sort of, well, wearable workflow management system, to manage this wearable workflow!

Well, that’s my nutty idea, and I’m sticking to it. In fact, I’m giving the keynote at the Healthcare Systems Process Improvement Conference in Orlando during February, about this exact topic! Anyway, that’s why asked the question, and here’s my favorite tweets. Actually, there were so many creative and funny I’d I think I include a bunch here…

My next questions, “What is the nuttiest, craziest, “wearable workflow” idea (lifehack or healthcare) you can toss out there?” was like throwing an armful of tinder on a pile of already lit matches! There were so many wonderful nutty/good ideas I can’t just highlight one. But I can’t simply embed a bunch tweets here either. Next month I’m giving a webinar with the Society for Health Systems on “Wearable Workflow”. These tweets are worth a slide, perhaps some sort of word cloud. (I’ll have to think about that…).

Using RFID to track hospital gowns! Who’d want to take one home?! @Colin_Hung

Are smartphones “wearables”? @2HealthGuru (Thats an interesting question! Traditionally, no, but when they start interacting with wearables, such as when a smartphone notification causes you to take your smartphone, or when you wear a smartphone in a shoulder holster when running…)

McCoy’s StarTrek TriCorder @HealthFusionKMc (Kathy “McCoy”! Ha! I wonder if one of the roles of TriCoder-like smartphone functionality will be to collecting and interpreting data from smaller, implantable, swallowable wearable tech)

Hands-free patient care @VoceraCom (I think this will likely the biggest use for Google Glass certainly, see my trip report from the recent healthcare wearable conference)

Swallowables! @dz45tr (fun, how so many new words are being created for wearable-able-like tech… maybe we’ll have “fearables” by Halloween!)

Manage notifications across multiple devices @wareFLO (This was my idea. Do we really want the same notifications occurring in both Glass and our watches at the same time? We’ll need some way to manage info-flow and workflow across wearable devices)

Make wearables just part of life in Lifehack sense @dz45tr (I included the T2 Lifehack question for exactly this reason, wearable workflow is so “intimate” psychologically and physically that personal, professional, and workaday workflows will necessarily sort of merge…)

Patient GPS for indoor navigation @jalfson (I think this is wonderful idea. Of course, until, and unless, Glass-like heads-up-displays become more prevalent among consumers, the hospital may have to “provision” patients with the devices. BTW, these folks are working on something similar, though not in a healthcare context)

Translation tool, doc-speak to lay-speak too @uhna_engels (Folks are working on the human language to human language aspect, not to my knowledge technical to folk terminology, may be version of previous idea)

SMS/Texting key component of any workflow approach/text message metadata/structure sent and returned @ShimCode (As more and more of our workflow is through texting, especially due to wearable form factors — those tiny screens! — we’re going to need to manage that workflow better, and that is going to require some sort of structured metadata)

Replace bad TV/promo mags with patient-relevant content @uhna_engels Lots of excellent wearable workflow ideas from Uhna! (Assumes consumers show up in medical offices wearing Glass or similar. Ha! I’m reminded of this tweet about who folks get absorbed in watching videos on Glass and look really weird to the folks around them.

Identify “swiss cheese” holes in workflow @lzipperer (I think Lorri is referring to Reason’s Swiss Cheese model of healthcare system failure. Mistakes happen, and have consequences, when the “holes” in successive layers of systems line to to allow an error to cause something bad to happen. Glass could be useful in two ways, that I can think of: (1) recording video of workaday events for retroactive analysis, and (2) proactive monitoring and guidance to prevent those holes from lining up.)

“Omniscient systems” @dz45tr@2HealthGuru (not sure, what this is, but sounds interesting! There’s a reference to SkyNet, the computer in the Terminator movie trying to exterminate humans. But I do think that we’ll need some sort of intelligent workflow layer to manage not just individual wearable devices, but also workflow, that is, user experience, across wearable devices. “Omniscient” carries the idea too far, but perhaps simply “knowledge across wearable device and user or team context” works…)

Wow! What an incredible outpouring of nutty/crazy/just-might-work ideas!

My next question: T4? Come’on… you knew I was going to ask about something kind of technical and jargony having to do with workflow technology.

OK, finally, I asked for substantive links to content — case studies, white papers, videos, etc. — from people who actually have something to sell! Oh, shame on me… But, truthfully, as I said at the outside, we need more than noisy #HITsm influencers and bloggers, we need actual software and services, combined by the right consulting expertise with native EHR and HIT system user experience, common sense, and creativity, if… we are going to substantiality improve healthcare workflow flexibility, transparency, effectiveness, efficiency, quality, consistency, throughput, and user and patient satisfaction.

That is why I invited who I invited to the 8/22/14 #HITsm on healthcare workflow!

If you are interested in healthcare workflow, want to find people to follow on Twitter interested in healthcare workflow (I’m @wareFLO, ahem!), or want to show off what you know about healthcare workflow, just search Twitter for the #HITsm hashtag from 12 to 1 EST on Friday, August 22nd. If you see something interesting you want to respond to, include the #HITsm hashtag in your tweet and others will see your tweet and do the same. Got it? You can also include the number of the question or theme, T1 through T5 (see below).

T2: Workflow isn’t always about work. Do you have an interesting “Lifehack” to share? (Lifehacks are novel or even inspiring improvements to personal workflow increasing efficiency and productivity.).

T3: Wearable technology — smartwatches, Google Glass, sensors strapped to all sorts of places — have implications of workflow in the Lifehack sense. Blueskying it, what is the nuttiest, craziest, “wearable workflow” idea you can toss out there?

T5: Do you sell software or services that improve healthcare workflow? Introduce yourself (in a low-key manner) and include a link to substantive content (white paper, video, technology description, etc.) illustrating how you do it!

How did I choose these questions? Let me explain, and then define what I mean by workflow and workflow tech.

Everyone in health IT has drawn out workflows for some process, or participated in similar. The Lifehack question is fun and relevant. Personal and professional workflows are full of workflow “hacks”. And the idea of “life hacking” is relevant to “wearable workflow”, ways in which smartwatches, smartglasses, smartrings, smartshoes and so on *might* improve personal and professional workflows. Business Process Management? Workflow engines executing process definitions greater by graphical editors (and a whole lot more). They’re increasingly showing up in healthcare and health IT, though sometimes rebranded as Care or Healthcare Process Management. Finally, health IT vendors play an important role in diffusion ion healthcare of what academics call “process-aware” tech.

Workflow

Workflow is any series of task steps, consuming resources (time, money, supplies, but particularly mental effort and attention), achieving one or more goals. Essentially all purposeful activity relies on workflow. ‎This means you can pivot from workflow to almost any area of healthcare: e-prescribing workflow, workflow of content management, managing your professional health IT job workflow, etc.

Workflow Technology

Any tool or machine used by humans to create value is technology. So, potentially, any tool or machine to improve effectiveness, efficiency, or flexibility of workflow is workflow technology. Workflow tech also involves some sort of model of workflow or work. This model may be prescriptive about step sequence, or it may be high-level and relatively non-prescriptive, perhaps noting goals, subgoals, resources, etc.

This workflow model/model of work may be executed by computer, but it can also be studied and consulted during execution by humans. The model may be in some formal notation (such as BPMN) or it may just be labeled boxes and arrows on the back of a napkin. In fact, a model of work does not even have to be written down, it can be a shared mental model! You and I can discuss workflow, develop a shared mental model, and use that model to better coordinate our joint efforts. And that’s workflow tech too. A model of workflow may be explicit or implicit (such as in machine learning “weights” that learn to predict and help your workflow, such as in Google Now).

P.S. The following is a copy of an earlier version of this post, basically a place holder to get the word out early. The vacation question? Took it out due to other questions competing for time. But feel free to answer it anyway!

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Published: AUGUST 3, 2014

Well, I’ve gone and got myself roped into moderating a #HITsm Tweetchat. If you are interested in healthcare workflow, want to find people to follow on Twitter interested in healthcare workflow, or want to show off what you know about healthcare workflow, just search Twitter for the #HITsm hashtag from 12 to 1 EST on Friday, August 22nd. If you see something interesting you want to respond to, include the #HITsm hashtag in your tweet and others will see your tweet and do the same. Got it? You can also include the number of the question or theme, T1 through Tn (see below).

By the way, I won’t be nearly as good as such moderators as @ochotex, @mandibpro and @dz45tr (BTW “disaster”! Get it?). Why? Two reasons come to mind: I only really care about one topic (workflow, most #HITsm twepes have more diverse interests) and, yes, I’m argumentative. So, “moderate”, as in “moderator”, I’m not.

Still, I’m honored to be ask‎ed! I’ll do my best. And if healthcare workflow benefits, even vaguely, ambiguously or indirectly, fantastic!

“Workflow” means a lot of things to a lot of people. So I’ll lay out what I mean by it. But any other working definition at all will be welcomed. In fact, just show up for the incredible camaraderie! ‎I know I do lots, even when the subject isn’t workflow. The back-and-forth joshing is infectious.

Workflow is any series of task steps, consuming resources (time, money, supplies, but particularly mental effort and attention), achieving one or more goals. Essentially all purposeful activity relies on workflow. ‎This means you can pivot from workflow to almost any area of healthcare: e-prescribing workflow, workflow of content management, etc.

OK, what is workflow technology then? Workflow tech is more than just workflow definitions, created by workflow editors, executed by workflow engines. (Though I do go on about those a lot, don’t I!?). Any tool or machine used by humans to create value is technology. So, potentially, any tool or machine to improve effectiveness, efficiency, or flexibility of workflow is workflow technology.

However, I will place one constraint on the above definition of workflow technology. Workflow tech involves some sort of model of workflow or work. This model might be very prescriptive about step sequence, or it can be very high-level and relatively non-prescriptive, perhaps just noting goals, subgoals, resources, etc.

This workflow model/model of work may be executed by computer, but it can also be studied and consulted during execution by humans. The model may be in some formal notation (such as BPMN) or it may just be labeled boxes and arrows on the back of a napkin. In fact, a model of work does not even have to be written down, it can be a shared mental model! You and I can discuss workflow, develop a shared mental model, and use that model to better coordinate our joint efforts. And that’s workflow tech too.

The following are just draft questions for the August 22 “even”. I’m open to addition or substitution. I’m writing this post almost three weeks prior to the #HITsm tweetchat so we’ve got plenty of time to come up with even better questions!

While I’ll introduce each questions every 5 or 10 minutes, as far as I am concerned, any of the following can be addressed at any time between Noon and One o’clock. So feel free to jump right in with T4-T6 right out of the gate! One bit of advice, make your tweet “self-contained” as much as possible, meaning not requiring someone to look up the original question in order to understand your central point. I’ll be retweeting lots to my 4,400+ followers and I want them to benefit, even if they have the audacity not to participate in the #HITsm tweetchat!

T2: Workflow isn’t always about work. Do you have an interesting “Lifehack” to share? (Lifehacks are novel or even inspiring improvements to personal workflow increasing efficiency and productivity.).

T3: Intermission question! Have you recently been, or are you currently at, or will you soon go to some cool vacation destination? Details!

T4: Wearable technology — smartwatches, Google Glass, sensors strapped to all sorts of places — have implications of workflow in the Lifehack sense. These include patient monitoring or engagement sense, and the provider health IT user experience sense. “Notifications” are an important function of some wearables. Notifications are similar to alert and reminders in workflow systems. So, blueskying it, what is the nuttiest, craziest, “wearable workflow” idea you can toss out there?

T6: Do you sell software or services that improve healthcare workflow? Introduce yourself and include a link to substantive content (white paper, video, technology description, etc.) illustrating how you do it!

Anyway, if you are interested in healthcare workflow, I hope you’ll participate, or at least lurk (and then give into any sudden impulses to participate!) August 22, Noon to One EST, around the #HITsm coffee cooler!

One more thing. I’ll be giving away a special workflow-related gift to the person who tweets most from Noon to One on August 22 on the #HITsm hashtag!